We return to Alicia, a 35 year old woman with borderline personality disorder (BPD). She has a history of cutting herself, difficulty maintaining jobs, and volatile relationships. She is currently going through a divorce. After 1 year of monthly visits together in primary care, you reviewed the diagnostic criteria for BPD with Alicia and discussed the diagnosis of BPD with her. You recommended that Alicia connect with a therapist who specializes in dialectical behavioral therapy (DBT), but she has been unable to do so over the past 6 months. She has continued to follow up with you consistently every month.
Today, Alicia is very upset – she is feeling lonely and left out as the holidays approach and is ruminating about her marriage and divorce. She tells you that she is cutting herself again, for the first time in 5 years.
How do you support a patient with self-harming behaviors?
Why do people self-harm?
Non-suicidal self-harming behaviors most commonly involves cutting or burning. They are not performed with suicidal intent (Prada 2018). Self-harming behaviors are common in patients with BPD and occur across a range of psychiatric illnesses, usually in states of emotional turmoil or dissociation. Patients with BPD experience intense fluctuations in emotions that are unpredictable and overwhelming; patients may turn to maladaptive coping strategies, like self-harm, to deal with the heightened emotional distress (Bohus 2021). Self-harming behavior can serve different functions: dampening painful emotions, avoiding feelings of emptiness, and bringing closeness or, alternatively, creating distance in relationships (Leichsenring 2023). While these behaviors may be dysfunctional in some ways, they are also effective emotional regulation tools for patients, relieving suffering and tamping down emotional intensity (Prada 2018).
What can you do as a clinician?
Distinguish between suicide attempts and self-harm (also called non-suicidal self-injury)
2-10% of patients with BPD end their life by suicide (Bohus 2021). The key question to distinguish between suicide attempts when a patient intends to end their life, and non-suicidal self-injury when there is another goal, is “What did you hope would happen when you [cut, burned, etc] yourself?” The injuries of suicidal self-injury and suicide attempts can be identical. The intention behind the act distinguishes the two.
Talk with patients about suicidal thoughts and behaviors (if applicable) and assess for suicidal risk (see prior PsychSnap).
Discuss the self-harming behavior with the patient
Therapists will use chain or functional behavioral analysis to explore the chain of components leading to a specific behavior: what prompts the behavior, what maintains the behavior, and what needs to change/be solved so that the behavior can stop (Prada 2018). This is a powerful tool that requires specialized training.
Within primary care, one can try to understand if there are specific triggers for the current self-harming behavior, provide some guidance and support related to the trigger itself (relationship arguments, worsening sleep, increased alcohol use), and offer distress tolerance skills that can be substituted for the self-harming behavior if the patient is interested.
A clinician’s guide to talking about and managing self-harming behaviors
Learn more about self-harming behaviors through empathic, open-ended questions. This is often a very vulnerable conversation for patients, so be sure to offer supportive responses and ensure you have time for follow-up questions.
Screen for self-harming behaviors
- Have you ever intentionally injured yourself or your body? Can you tell me more about that?
Understand current self-harming behaviors
- When do you [engage in this behavior]? Be sure to use the patient’s words – When do you cut? When do you burn your arm? When do you bang your head?
- How do you feel right before you [engage in this behavior]?
- What do you think (hope) will happen when you [engage in this behavior]?
- How do you feel afterwards?
Clarify the current trigger for self-harming behavior
- Is there something going on right now in your life that prompted you to harm yourself? Tell me more about that.
Assess vulnerability factors that may be modifiable
- Ask patients about difficulties with sleep, alcohol or other substance use, lack or loss of social support.
Manage self-harming behavior through counseling
- Avoid inpatient crisis treatment for behavior that is not life-threatening (Bohus 2021).
- Problem solve around identified triggers that you are able to counsel on (such as difficulty with sleep or substance use).
- Offer your patient skills from Dialectical Behavioral Therapy (DBT) (Linehan 2014). DBT has 4 key components: emotional regulation, mindfulness, distress tolerance, and interpersonal effectiveness. Distress tolerance skills specifically address crisis situations and the significant emotional suffering that patients may experience (Prada 2018).
The STOP skill can be used to help people avoid impulsive actions (including self-harm) based on emotions (Linehan, 2014). Provide your patient this list of 4 actions to go through during moments of crisis.
- S: STOP, freeze, don’t do anything.
- T: TAKE a step back, breathe, don’t do anything until the intensity of the feeling decreases.
- O: OBSERVE, what is going on inside you and around you, what are you feeling, what are others doing. Gather the relevant facts to understand what is going on and what the available options are.
- P: PROCEED mindfully, act with awareness of your thoughts, the situation, others’ feelings. What do I want? What choice might make the situation better or worse?
Cold water can be used when one has the urge to self-harm or is overwhelmed by intense emotions. Provide your patient with the cold water exercise explained here (Linehan, 2014).
- Hold your breath, and put your full face into a bowl or sink of cold water. Alternatively, put a zip-lock bag with ice cold water on your eyes and upper cheeks while bending forward.
- Stay there for 30-60 seconds until it starts to become uncomfortable, but not painful, to elicit the “dive response.” This tells your brain you are diving underwater and kick starts the parasympathetic nervous system after 15–30 seconds. The heart rate slows down, blood flow to nonessential organs is reduced and redirected to the brain and heart.
- The dive response can help reduce strong emotions quickly and can be used as part of the T – TAKE a step back in STOP.
Treat co-occurring illness
- Assess for co-occurring illness (most commonly, major depression, bipolar disorder, anxiety, and substance use disorders) and offer treatment, including therapy and medications as indicated. No specific medications have been shown to consistently treat borderline personality disorders or reduce self-harming behavior (Gunderson 2019).
What can you do long term?
Ideally, all patients with BPD should have the opportunity to participate in psychological therapy for BPD. A 2020 Cochrane review noted that self-harming behavior can improve with psychological therapy (Storebø 2020). Focus on helping your patient obtain access to therapy. Continue to see your patients with BPD regularly.
Back to Alicia
You discuss cutting with Alicia. She has been feeling neglected and alone. She does not want to end her life. Cutting helps to focus her mind and lets her body relax. She always cuts on her left thigh with a box cutter. She doesn’t like the scars, but she doesn’t know what else to do.
You express empathy for her loneliness and concern around her self-harm. You ask if she has ever tried to do something else, instead of cutting? She hasn’t, but she’s up for trying. You teach her the cold water exercise to try when she is distressed. You remind her of the importance of therapy and the likelihood that it will be helpful to her; she plans to investigate the list of available therapists on her insurance website.
Key Points
- Patients with BPD may engage in suicidal and non-suicidal self-harming behavior; intention is what differentiates the two.
- Self-harming behavior is a maladaptive coping skill for emotional distress that serves different functions for different patients. Self-harm may dampen painful emotions, decrease feelings of emptiness, and bring closeness or create distance in relationships.
- Openly and empathetically discuss self-harming behavior with your patient. Ask about current triggers, co-occurring illness including substance use, and offer basic distress tolerance skills. Avoid hospitalization for non-suicidal behavior.
Related PsychSnaps:
“How do you talk with patients about suicidal thoughts and behaviors?” Emma Samelson-Jones, April 2024.
“How do you diagnose and manage borderline personality disorder in primary care?” Zoë Kopp, October 2024.
References:
Bohus, M., Stoffers-Winterling, J., Sharp, C., Krause-Utz, A., Schmahl, C., & Lieb, K. (2021). Borderline personality disorder. The Lancet, 398(10310), 1528–1540.
Gunderson, J. G., & Choi-Kain, L. W. (2019). Working With Patients Who Self-injure. JAMA Psychiatry, 76(9), 976.
Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., & Kernberg, O. F. (2023). Borderline Personality Disorder: A Review. JAMA, 329(8), 670.
Linehan, M. (2014). DBT Skills Training Manual (2nd ed.). Guilford Press.
Prada, P., Perroud, N., Rüfenacht, E., & Nicastro, R. (2018). Strategies to Deal With Suicide and Non-suicidal Self-Injury in Borderline Personality Disorder, the Case of DBT. Frontiers in Psychology, 9, 2595.
Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 2020(11).